Nurse Anesthetists Planning to Oppose VA Rule

Will show data in their quest to practice independently within the VA

The Department of Veterans Affairs (VA) decision not to allow nurse anesthetists to practice independently in VA facilities will not be the last word on the subject -- if the nurse anesthetists have anything to do with it.

"We definitely have a strategy -- we are not unprepared, just like in our anesthesia lives we're not unprepared," Cheryl Nimmo, DNP, president of the American Association of Nurse Anesthetists, told MedPage Today in a phone interview.

On Tuesday, the VA published a final rule regarding the role of advance practice nurses working in VA facilities. "The Department of Veterans Affairs (VA) is amending its medical regulations to permit full practice authority of three roles of VA advanced practice registered nurses (APRN) when they are acting within the scope of their VA employment," the agency said in the rule.

"Certified Registered Nurse Anesthetists (CRNA) will not be included in VA's full practice authority under this final rule, but comment is requested on whether there are access issues or other unconsidered circumstances that might warrant their inclusion in a future rulemaking."

Although nurse anesthetists did not get the go-ahead, three other types of advanced practice nurses did: certified nurse-midwives, nurse practitioners, and clinical nurse specialists. "By permitting [these] three APRN roles ... throughout the VHA [Veterans Health Administration] system with a way to achieve full practice authority in order to provide advanced nursing services to the full extent of their professional competence, VHA furthers its statutory mandate to provide quality health care to our nation's veterans," wrote the authors of the rule.

The rule comes with a 30-day comment period. "We will take advantage of the comment period that they've given us," said Nimmo. "We will bring a lot of the original data and studies -- and more."

Nimmo noted that the VA said there was not a shortage of anesthesia providers within its system. "While that might be the case, the problem is that the number of people in line to have surgery, to have interventional procedures done, to have open heart surgery, to have colonoscopies done, extends very far down the wait list -- and many [VA anesthesiologists] are not providing anesthesia; they're supervising CRNAs who are providing anesthesia. If you remove that requirement, those providers could also provide anesthesia and cut the wait times down. You would have more providers, shorter wait times, and it wouldn't cost VA any more taxpayer dollars."

Nimmo noted that 10 research studies on anesthesia quality and safety that have been published in peer-reviewed journals "show we are as safe as anesthesiologists -- working by ourselves, working with them, the outcomes are no different for any group. The VA's own Commission on Care recommended that all the advance practice nurses, including CRNAs, be granted full practice authority, and the data in the VA's independent assessment report confirms there are many long delays for healthcare services that require anesthesia care. So they're not even following their own assessment recommendations."

In fact, she added, "the VA confirmed that CRNAs are qualified for full practice authority but they didn't include us with other advance practice nurses because they don't view access to anesthesia care as an issue."

State laws regarding supervision for nurse anesthetists vary, according to Nimmo. In 28 states, there is no requirement for supervision, and in the remaining 22 states physician supervision is required, which could include the surgeon, oral surgeon, podiatrist, or whoever is performing the procedure. No state specifies that a supervising physician must be an anesthesiologist, she said.

Although most physician groups who have spoken out on the issue -- such as the American Society of Anesthesiologists -- have agreed with the VA's decision on nurse anesthetists, some individual physicians disagreed.

"My practice is an office-based surgical practice wherein I have utilized CRNAs for all of my IV anesthesia procedures," said a comment posted with an earlier MedPage Today story on the decision. "The CRNAs who work with me have all been well trained and well educated ... CRNAs are a valuable part of any surgical team and should be able to provide anesthesia services within their scope."

Nursing organizations also spoke out against leaving nurse anesthetists out of the rule. "America's nurse practitioners are honored to continue to serve our nation's veterans by providing them with direct access to the high-quality health care they deserve," Cindy Cooke, DNP, president of the American Association of Nurse Practitioners, said in a statement. "We trust that in the near future, the VA will propose a plan to include Certified Registered Nurse Anesthetists (CRNAs) in this provision."

The American Nurses Association (ANA) voiced similar sentiments. "ANA is concerned with the final rule's exclusion of CRNAs, which is solely based on the VA's belief that there is no evidence of a shortage of anesthesiologists impacting access to care," ANA president Pamela Cipriano, PhD, said in a statement. "We join with our colleagues in continuing to advocate for CRNAs to have full practice authority within the VA health care system."

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